USDA Health Policy


USDA Policy #3 --- Veterinary Care--- April 14, 1997 -- Last revision on January 14, 2000 Section: Policy on Health Records.

References: AWA Section 13 and 9 CFR, Part 2, Sections 2.31, 2.32, 2.33, 2.40 and 9 CFR, Part 3, Section 3.110

History: Provides requested guidance. Replaces memoranda dated May 31, 1990, November 29, 1991, April 6, 1992, and September 25, 1992. The previous version of this policy released on April 14, 1997, has been modified to include "Health Records."

Justification: The Animal Welfare Act (AWA) requires that all regulated animals be provided adequate veterinary care.


Health records are meant to convey necessary information to all people involved in an animal's care. Every facility is expected to have a system of health records sufficiently comprehensive to demonstrate the delivery of adequate health care. For those facilities that employ one or more full-time veterinarians, it is expected there will be an established health records system consistent with professional standards that meets and probably exceeds, the minimum requirements set forth in this policy. For facilities that do not employ a full-time veterinarian, it is suggested the health records system be explained as part of the written PVC, to ensure involvement of the attending veterinarian in developing the system. For all facilities, health records must be current, legible, and include, at a minimum, the following information:

  • Identity of the animal.

  • Descriptions of any illness, injury, distress, and/or behavioral abnormalities and the resolution of any noted problem.

  • Dates, details, and results (if appropriate) of all medically-related observations, examinations, tests, and other such procedures.

  • Dates and other details of all treatments, including the name, dose, route, frequency, and duration of treatment with drugs or other medications. ( A "check-off" system to record when treatment is given each day may be beneficial.)

  • Treatment plans should include a diagnosis and prognosis, when appropriate. They must also detail the type, frequency, and duration of any treatment and the criteria and/or schedule for re-evaluation(s) by the attending veterinarian. In addition, it must include the attending veterinarian's recommendation concerning activity level or restrictions of the animal.

  • Examples of procedures which should be adequately documented in health records include, but are not limited to, vaccinations, fecal examinations, radiographs, surgeries, and necropsies. Routine husbandry and preventive medical procedures (e.g., vaccinations and dewormings) performed on a group of animals may be recorded on herd-health-type records. However, individual treatment of an animal must be on an entry specific to that animal. As long as all required information is readily available, records may be kept in any format convenient to the licensee/registrant (e.g., on cage cards for rodents).

    Health records may be held by the licensee/registrant (including, but not limited to, the investigators at research facilities) or the attending veterinarian or divided between both (if appropriately cross-referenced), but it is the responsibility of the licensee/registrant to ensure that all components of the records are readily available and that the record as a whole meets the requirements listed above.

    An animal's health records must be held for at least 1 year after its disposition or death. (Note: Some records may need to be held longer to comply with other applicable laws or policies.) When an animal is transferred to another party or location, a copy of the animal's health record must be transferred with the animal. The transferred record should contain the animal's individual medical history, information on any chronic or ongoing health problems, and information on the most current preventive medical procedures (for example, the most recent vaccinations and dewormings). For traveling exhibitors, information on any chronic or ongoing health problems and information on the most current preventive medical procedures must accompany any traveling animals, but the individual medical history records may be maintained at the home site.